Ready to Schedule Westchester

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IV Ketamine isn't a fit for certain people. If you are in a life threatening situation, call the National Suicide Prevention Line at *988 or visit your nearest emergency room. Responses are not monitored in real-time by NYKI.
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Full Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Please enter a valid phone number.
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Email Address* This field is required.
example@example.com
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Reason for your visit?* This field is required.Select a Condition
Please Select
Please Select
Depression
Anxiety
PTSD
OCD
Bipolar Disorder
Neuropathic Pain
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Were you referred by a physician?
Yes
No
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What is your physicians name?
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How did you hear about us?* This field is required.
Podcast
Press Coverage
Social Media
Email
Online Research
Event
Physician Referral
Patient Referral
Print Campaign
Radio
Other
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Tell us more about your condition for your consultation.* This field is required.
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How familiar are you with the benefits of ketamine therapy for anxiety and depression?* This field is required.
I’d never heard about ketamine therapy until today
I have heard a little about ketamine therapy
I’m very familiar with ketamine’s therapeutic potential
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Are you currently taking any of the following medications: Benzodiazepines, Gabapentin, or Lamotrigine.
Yes
No
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Please provide more information* This field is required.
I’m currently taking more than 1.5MG of Klonopin or Xanax
I’m currently taking more than 300MG of Gabapentin or Perdaytanex
I’m currently taking more than 150MG of Lamotrigine
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To provide the best treatment we need to know if any of the following apply to you?* This field is required.Please select all that apply to you.
Under 18
Primary psychotic disorder (e.g. schizophrenia, schizoaffective disorder)
Biological female who is pregnant, nursing or trying to conceive
Uncontrolled high blood pressure despite treatment
You consider yourself to be dependent on alcohol or any other substances
I’ve been hospitalized in the past 30 days for a mood disorder
None of the above
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I understand that as a new patient of NYKI, it is recommended that I complete an initial series of six infusions over the course of a two week period.
Yes
No
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I understand the cost of treatment and that each individual treatment cost $525 for a total cost of $3,150, and is typically not covered by insurance. Patients will also typically receive 3-6 booster treatments over the course of 12 months.
Yes
No
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AcknowledgementI hereby confirm that I have answered all questions honestly and to the best of my ability. Please click submit below to complete the form.
I Agree
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